Provider Demographics
NPI:1952306219
Name:ANTHONY, PAUL A (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:A
Last Name:ANTHONY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4650 JEFFERSON LN NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2127
Practice Address - Country:US
Practice Address - Phone:505-889-9639
Practice Address - Fax:505-889-2978
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01077206A2085R0203X, 2085R0001X
NM86-1652085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM92616OtherFIRST HEALTH PLAN
NM300065574OtherMEDICARE RAILROAD
NM5614250OtherAETNA/ PRONET
NMNM000168OtherBLUE SHIELD/NM
NM37770Medicaid
NM9214OtherLOVELACE HEALTHPLAN
NM261909OtherAHCCCS
NM261909OtherAHCCCS